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American Journal of Epidemiology logoLink to American Journal of Epidemiology
. 2024 Mar 21;193(11):1519–1529. doi: 10.1093/aje/kwae024

Assessing trends in internalizing symptoms among racialized and minoritized adolescents: results from the Monitoring the Future Study 2005-2020

Navdep Kaur ✉, Paris B Adkins-Jackson, Victoria Joseph, Mia N Campbell, Katherine M Keyes
PMCID: PMC13070528  PMID: 38517022

Abstract

The prevalence of depressive symptoms has rapidly accelerated among recent US adolescent birth cohorts, yet there remains little understanding of trends among racialized and minoritized groups. These groups may experience depressive symptoms due to the deleterious effects of structural racism. Using 2005-2020 Monitoring the Future survey data, we examine all racialized groups using within-group analyses to observe trends in high levels of depressive symptoms across cohorts. Generally, across racialized groups and ages, the odds of high depressive symptoms increased in recent birth cohorts. For example, among 15- to 16-year-old students racialized as American Indian or Alaska Native and Black Hispanic/Latine, the 2003-2006 birth cohort had 3.08 (95% CI, 2.00-4.76) and 6.95 (95% CI, 2.70-17.88) times’ higher odds, respectively, of high depressive symptoms as compared with the 1987-1990 birth cohorts. Moreover, in a given year, 15- to 16-year-olds generally experienced the highest depressive symptoms compared with 13- to 14-year-olds and 17- to 18-year-olds, suggesting that age effects peaked during midadolescence. Depressive symptoms increased among US adolescents by birth cohort, within all racialized and minoritized groups assessed. Public health efforts to reduce disparities may consider barriers such as structural racism that may impact the mental health of racialized/minoritized adolescents while increasing access to culturally competent mental health providers and school-based services.

This article is part of a Special Collection on Mental Health.

Keywords: adolescents, internalizing symptoms, racialized groups, minoritized groups, Monitoring the Future

The prevalence of adolescent major depressive disorder1 has increased in the United States since the 2000s. Core to depressive disorders and suicidal behavior is the disruption of the sense-of-self and self-worth that comprise central internalizing symptoms,2 referring to one’s thoughts, feelings, and behavior. These internalizing symptoms are indicative of anxiety and depression, social withdrawal, and somatic complaints.3 Depressive symptoms, a multidimensional construct that includes mood-related changes in affect, behavior, and cognition,4 are associated with increased substance use5-8 and suicide.9,10

Evaluation of trends in internalizing symptoms among adolescents is critical for designing targeted interventions for groups made vulnerable through structural and social determinants of health. The overall prevalence of depressive symptoms has increased among adolescents since 2012, with the overall magnitudes of the increase being similar across emerging birth cohorts of adolescents.11,12 Across the life course, recent birth cohorts have experienced higher levels of depressive symptoms in midlife than earlier cohorts.13,14 This trend is consistent across other indicators of poor mental health.15

However, there remains little understanding of trends within racialized and minoritized adolescent groups. Studies of period effects suggest that adolescents racialized as White have experienced faster increases in the prevalence of depression than adolescents racialized as Black in the United States,16 but cohort differences have not been adequately interrogated. Feelings of loneliness, a facet of internalizing symptoms, have increased for racialized and minoritized adolescents racialized as Hispanic and “non-Hispanic other” but have not increased among adolescents racialized as Black.11 Studies of persons racialized as Asian/Asian American found that internalized racism through the adoption of the “model minority” myth17,18 was associated with increased mental health issues in this group.19 More broadly, adolescents racialized as Asian American, Native Hawaiian, Pacific Islander, or Hispanic/Latine face mental health stressors from xenophobia and intergenerational conflict due to acculturation that result in increased levels of depressive symptoms.20 Investigations of age-related trends demonstrate that adolescents and young adults racialized as Black or Latine often report the highest exposure to traumatic events,21,22 and racialized and minoritized adolescents in particular are exposed to several racialized drivers of depressive symptoms, including racial discrimination over social media23,24 and in school.25,26 Taken together, these studies suggest that racialized and minoritized individuals are particularly vulnerable to experiencing depressive symptoms during adolescence. Despite these contributions, minimal studies have explored trends in depressive symptoms among adolescents who experience multiple forms of structural oppression.27-29

Moreover, most studies have not assessed trends in depressive symptoms among adolescents racialized as Native American/Alaska Native, Asian/Asian American, or Native Hawaiian/Pacific Islander, all of whom have unique lived experiences of structural racism that may lead to poor mental health.11,16,30-32 Indeed, these groups experience chronic structural racism within epidemiologic research when such individuals are grouped into racial categories or lumped together as “other,” leading to erasure of investigators’ ability to assess unique health-status differences.33 The sparse literature on one of these groups suggests that the prevalence of mental health disorders among youth racialized as Indigenous increases with age34; however, particular cohorts with a higher burden of internalizing symptoms have not been identified.

In the present study, we used Monitoring the Future (MTF) data (2005-2020) to investigate accelerated trajectories of depressive symptoms by birth cohort and time-period trends in depressive symptoms among racialized and minoritized adolescents. We hypothesized that depressive symptoms are more prevalent in recent birth cohorts of racialized and minoritized adolescents, consistent with previous literature.11 Our goal was to identify racialized and minoritized adolescent cohorts with particularly high levels of depressive symptoms to inform public health intervention efforts.

Methods

Sample

MTF investigators annually administer cross-sectional surveys of 8th-, 10th-, and 12th-graders in the contiguous United States. Approximately 420 US public and private high schools were selected to participate in the MTF Study using a multistage random sampling design (maximum of 350 students per school). Selected schools were invited to participate for 2 years, and those that declined were replaced. The present study used cross-sectional data collected annually between 2005 and 2020. Survey year 2005 was chosen as the first year because measurement of racialized groups was updated in that year. Student response rates within schools ranged from 79% (12th grade in 2008 and 2020) to 91% (8th grade in 2006, 2007, 2011, and 2012), with most nonresponses being due to absence on the day of survey administration.35 Active parental dissent was used for consent.36,37 Two weeks before the study, parents of sampled students were sent a letter and an informational flyer about the MTF survey. Parents who chose not to have their child participate in the study were required to sign a form included in the letter. We used sample weights provided by MTF in all calculations that reflect the multistage sampling design and generate nationally representative estimates. MTF investigators obtained institutional review board approval from the University of Michigan and Columbia University.

The MTF survey comprised a core form given to all students and randomly assigned subforms. We focused on students who received subforms that included questions regarding internalizing symptoms. The maximum sample size was 213 924 (84 767 8th-graders, 88 748 10th-graders, and 40 409 12th-graders). Nonresponse rates for covariates were low, with the highest missingness pertaining to the racialized group question (17.0%) and the outcome measure (3.84%) among students racialized as American Indian or Alaska Native. To address missing data, multiple imputation using the fully conditional specification (FCS) method was performed using the FCS statement in “PROC MI” in SAS, version 9.438, with 15 imputations incorporated in all analyses.38

Measures

Depressive symptoms.

Four items measured depressive symptoms: (1) “Life often seems meaningless…”; (2) “The future often seems hopeless…”; (3) “I enjoy life as much as anyone…”; and (4) “It feels good to be alive.” These items are similar to those on the Center for Epidemiologic Studies Depression Scale,39 were used in prior research,5,12,40-42 and demonstrated excellent internal consistency across the 3 grades.12 Response options for each statement were scored on a Likert scale (disagree, mostly disagree, neither, mostly agree, agree), and positive statements were reverse-coded. We then used these values to create a composite measure, and scores ranged from 4 points to 20 points. Depressive symptom scores were highly right-skewed and did not meet normality assumptions for linear models. Because there is no empirically validated clinical cutoff score, we dichotomized scores at the 75th percentile to be consistent with other peer-reviewed studies using this measure from MTF.42,43

Birth cohort and age.

Age was measured in calendar years based on self-reported birth year and month and was categorized into 2-year age groups: 13-14 years, 15-16 years, and 17-18 years. Birth cohort was calculated as survey year (ie, period) minus age and ranged from 1987 to 2009. For ease of interpretation, we categorized birth cohort into 4-year groupings (1987-1990, 1991-1994, 1995-1998, 1999-2002, 2003-2006, and 2007-2009).

Race and ethnicity.

Students selected from a list of racialized categories, with the ability to select multiple categories: American Indian or Alaska Native, Asian American, Black or African American, Cuban American, Mexican American or Chicano, Puerto Rican, “other Hispanic or Latino,” Native Hawaiian or Pacific Islander, or White. Due to small sample sizes, we combined persons who selected Mexican American, Chicano, Cuban American, Puerto Rican, or “other Hispanic or Latino” into the category “Hispanic/Latine.” Since colorism contributes to the discrimination experienced by people racialized as Hispanic/Latine in the United States,27-29 we differentiated between Hispanic/Latine adolescents racialized as White and those racialized as Black. Studies of race/ethnicity and health most often filter respondents into mutually exclusive categories; however, this approach may misclassify students who select multiple categories. Therefore, we created 6 binary variables based on respondents’ racialized category selections, allowing respondents to be included in as many categories as they selected. The final racial/ethnic variables were American Indian or Alaska Native, Asian American, Black Hispanic/Latine, Native Hawaiian or Pacific Islander, non-Hispanic/Latine Black, and White Hispanic/Latine.

Analysis

We conducted within-group analysis to accentuate the unique mental health experiences of each racialized group without comparing it to adolescents racialized as non-Hispanic White, which inadvertently may suggest a hierarchy of need.44,45 We assessed the prevalence of the highest quantile of depressive symptoms by 2-year age group13-18 and 4-year birth cohort for each racialized group. Next, we assessed which cohorts and age groups had the highest levels of depressive symptoms within each racialized group. We used logistic regression models with the dichotomized measure of depressive symptoms as the dependent variables. We included birth cohort as an independent variable and fitted separate models for the 2-year age groups.13-18 We then graphed the predicted probabilities of a high level of depressive symptoms (≥75th percentile) derived from these models.

Results

Table S1 provides the prevalence of a high level of depressive symptoms for each racialized group, by age and birth cohort. Table 1 presents the odds of high depressive symptoms from the regression model for each racialized group by age group. Figures 1-6 present the predicted probabilities of high depressive symptoms from the regression model for each racialized group. Each line represents a different age group, graphed for the birth cohorts in which we include data for that age group. For example, among 13- to 14-year-old adolescents, we include data starting in the 1991-1992 birth cohort—that is, when adolescents completed the questionnaires starting in 2005; those who were aged 13-14 years before 2005 were in birth cohorts that were not included in our analytical sample.

Table 1.

Odds of high depressive symptoms among students in the Monitoring the Future Study (2005-2020), by race/ethnicity, birth cohort, and age.a

Race and ethnicity
Asian/Asian American Black Hispanic/Latine American Indian or Alaska Native Native Hawaiian or Pacific Islander Non-Hispanic Black White Hispanic/Latine
Age group and birth cohort OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI OR 95% CI
13-14 y
 1991-1994 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent
 1995-1998 0.77 0.61-0.99 0.74 0.50-1.11 1.22 0.96-1.56 1.19 0.80-1.79 1.23 1.04-1.44 1.00 0.73-1.38
 1999-2002 1.12 0.88-1.41 0.93 0.64-1.36 1.29 1.01-1.64 1.48 1.00-2.18 1.39 1.19-1.63 1.24 0.91-1.68
 2003-2006 1.64 1.31-2.06 1.49 1.03-2.16 2.13 1.69-2.68 1.77 1.19-2.64 1.73 1.47-2.03 1.59 1.17-2.16
 2007-2009 2.37 1.25-4.47 1.35 0.59-3.05 3.12 1.81-5.37 2.77 1.37-5.63 3.12 1.92-5.05 1.45 0.68-3.11
15-16 y
 1987-1990 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent
 1991-1994 2.94 1.73-4.98 3.44 1.34-8.79 1.56 1.03-2.37 3.48 1.54-7.85 2.78 2.11-3.66 1.58 0.85-2.95
 1995-1998 3.72 2.19-6.29 2.90 1.12-7.51 1.70 1.12-2.58 3.34 1.47-7.55 3.20 2.43-4.22 1.61 0.87-3.00
 1999-2002 4.54 2.70-7.65 4.98 1.98-12.57 1.97 1.30-2.99 5.52 2.46-12.41 4.20 3.19-5.51 2.35 1.27-4.32
 2003-2006 7.22 4.22-12.36 6.95 2.70-17.88 3.08 2.00-4.76 8.30 3.62-19.04 5.47 4.10-7.29 3.83 2.06-7.13
17-18 y
 1987-1990 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent 1.00 Referent
 1991-1994 1.37 0.98-1.90 0.71 0.39-1.31 1.03 0.66-1.60 1.06 0.61-1.82 1.43 1.14-1.79 0.67 0.39-1.17
 1995-1998 1.63 1.17-2.28 0.96 0.55-1.66 1.46 0.94-2.26 1.75 1.04-2.94 1.82 1.46-2.27 1.12 0.68-1.83
 1999-2002 3.90 2.89-5.27 2.05 1.23-3.42 4.10 2.75-6.12 3.56 2.19-5.80 3.79 3.08-4.68 2.05 1.29-3.27
 2003-2006 4.10 2.15-7.82 1.95 0.67-5.69 3.67 1.52-8.85 2.01 0.47-8.67 4.56 2.75-7.58 2.88 1.32-6.28
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Abbreviation: OR, odds ratio.

aFour questionnaire items were used to measure depressive symptoms: “Life often seems meaningless…”; (2) “The future often seems hopeless…”; (3) “I enjoy life as much as anyone…”; and (4) “It feels good to be alive.” Response options for each statement were scored on a Likert scale (disagree, mostly disagree, neither, mostly agree, agree). We used these values to create a composite measure for each internalizing symptom, and scores ranged from 4 points to 20 points. These scores were then dichotomized at the 75th percentile.

Figure 1.

Figure 1

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Predicted probability of experiencing depressive symptoms among American Indian or Alaska Native students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

Figure 6.

Figure 6

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Predicted probability of experiencing depressive symptoms among White Hispanic/Latine students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

Generally, across racialized groups and ages, the prevalence of high depressive symptoms increased in recent birth cohorts. Among students racialized as Asian/Asian American, non-Hispanic Black, and American Indian or Alaska Native, students aged 17-18 years had significantly higher odds of high depressive symptoms than did older cohorts (Table 1). For example, for students racialized as Asian/Asian American, the 2003-2006 birth cohort had 4.10 (95% CI, 2.15-7.82) times’ higher odds of high depressive symptoms than the 1987-1990 birth cohort. Among students racialized as non-Hispanic Black, the 2003-2006 birth cohort had 4.56 (95% CI, 2.75-7.58) times’ higher odds of high depressive symptoms than the 1987-1990 birth cohort. For students racialized as American Indian or Alaska Native, the 2003-2006 birth cohort had 3.67 (95% CI, 1.52-8.85) times’ higher odds of high depressive symptoms than the 1987-1990 birth cohort.

For students racialized as Native Hawaiian or Pacific Islander and Black Hispanic/Latine, students aged 15-16 years had significantly higher odds of high depressive symptoms than older cohorts of students (Table 1). Among students racialized as Native Hawaiian or Pacific Islander, the 2003-2006 cohort had 8.30 (95% CI, 3.62-19.04) times’ higher odds of high depressive symptoms than the 1987-1990 cohort. The 2003-2006 birth cohort for students racialized as both Black and Hispanic/Latine had 6.95 (95% CI, 2.70-17.88) times’ higher odds of high depressive symptoms than the 1987-1990 cohort. Among students racialized as White Hispanic/Latine, the 2003-2006 birth cohort had 3.83 (95% CI, 2.06-7.13) and 2.88 (95% CI, 1.32-6.28) times’ higher odds of high depressive symptoms for students ages 15-16 and 17-18 years, respectively, than the 1987-1990 birth cohort. Generally, 15- to 16-year-olds experienced the highest levels of depressive symptoms in a given year, suggesting that age effects of depressive symptoms peaked during midadolescence.

The predicted probability of high depressive symptoms increased across birth cohorts for all racialized groups. For students racialized as American Indian or Alaska Native, the predicted probability of high depressive symptoms increased across birth cohorts by 14.1 percentage points among those aged 13-14 years, 11.9 points among those aged 15-16 years, and 7.2 points among those aged 17-18 years (Figure 1). For students racialized as Asian/Asian American, the predicted probability increased by 9.4 percentage points among those aged 13-14 years, 16.3 points for those aged 15-16 years, and 8.1 points for those aged 17-18 years (Figure 2). For students racialized as Black Hispanic/Latine, the predicted probability of high depressive symptoms increased across birth cohorts by 3.4 percentage points among those aged 13-14 years, 16.8 percentage points among those aged 15-16 years, and 4.8 points for those aged 17-18 years. (Figure 3). Among students racialized as Native Hawaiian or Pacific Islander, the predicted probability of high depressive symptoms increased across birth cohorts by 12.2 percentage points among those aged 13-14 years, 17.7 points among those aged 15-16 years, and 3.4 points among those aged 17-18 years (Figure 4). Across all age groups of students racialized as non-Hispanic Black, the predicted probability of depressive symptoms increased across birth cohorts by 11.1 percentage points among those aged 13-14 years, 11.1 points for those aged 15-16 years, and 7.8 points for those aged 17-18 years (Figure 5).

Figure 2.

Figure 2

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Predicted probability of experiencing depressive symptoms among Asian/Asian American students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

Figure 3.

Figure 3

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Predicted probability of experiencing depressive symptoms among Black Hispanic/Latine students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

Figure 4.

Figure 4

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Predicted probability of experiencing depressive symptoms among Native Hawaiian or Pacific Islander students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

Figure 5.

Figure 5

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Predicted probability of experiencing depressive symptoms among non-Hispanic Black students in the Monitoring the Future Study (2005-2020), by birth cohort and age.

The predicted probability of high depressive symptoms among students racialized as White Hispanic/Latine increased across birth cohorts by 3.9 percentage points among those aged 13-14 years, 14.9 points among those aged 15-16 years, and 7.3 points among those aged 17-18 years (Figure 6). The largest observed increases were among those aged 15-16 years, whose depressive symptom probability increased from 6.7% for those born in 1987-1990 to 21.6% for those born in 2003-2006.

Discussion

The present study highlights increases in depressive symptoms among more recent birth cohorts of racialized and minoritized adolescents in the United States. Depressive symptoms increased by birth cohort (ie, across age) among all adolescents included in these analyses, highlighting the urgent need for prevention and intervention efforts that address mental health. Concentrated depressive symptoms across more recent birth cohorts of adolescents illuminate the ways in which marginalization continues to affect the youngest generations of US adolescents. The need for structural, culturally and linguistically appropriate intervention and prevention efforts is critical.

Adolescents racialized as Asian/Asian American in more recent birth cohorts reported more depressive symptoms, across all age groups investigated. Several factors may influence the mental health of adolescents racialized as Asian/Asian American residing in the United States. For instance, the “model minority” myth is the stereotype that persons racialized as Asian are more academically and economically successful than other racialized and minoritized groups due to their stereotyped work ethic and perseverance. The “model minority” myth paints persons racialized as Asian as a homogeneous racial group, when they actually represent at least 30 distinct ethnic groups experiencing unique socioeconomic challenges in the United States.46-48 Model minority stereotyping has historically been used to discount the racialized trauma experienced by communities racialized as Asian,49 and internalization of this myth has been linked to increased psychological distress among students racialized as Asian.50-52 The impact of this social phenomenon is exacerbated by rising anti-Asian racism that peaked during the COVID-19 pandemic, and undoubtedly contributed to poor mental health among youth racialized as Asian.53

Adolescents racialized as Black have experienced centuries of racialized trauma in the United States.54-57 Our study demonstrated increased high depressive symptoms in more recent cohorts of adolescents racialized as Black, which may be linked to intergenerational trauma,58 exposure to police brutality and increased police presence on school grounds,59 and continued socioeconomic oppression.60 Self-reported suicide attempts and related injuries among youth racialized as Black have increased for the past 3 decades despite decreases observed in other groups,61 highlighting the critical need for preventive interventions and mental health treatment for youth racialized as Black.

Depressive symptom increases among younger cohorts were also observed for adolescents racialized as Hispanic/Latine. These results are consistent with other national estimates of a higher incidence of suicidal behavior among adolescents racialized as Hispanic/Latine in recent years.62 Similar to all other racialized groups, adolescents racialized as Hispanic/Latine in the United States are widely diverse in national origin, language, culture, and experiences of discrimination and marginalization, making generalizations potentially unfit for observed patterns. Existing literature suggests that some adolescents racialized as Hispanic/Latine report depressive symptoms due to tensions between traditional values (eg, from family, culture, etc) and American norms,63-66 although such pathways do not explain rapid increases in more recent years. Recent increases in depressive symptoms among adolescents racialized as Hispanic/Latine are concordant with increasingly divisive political rhetoric aimed towards groups racialized as Latine. At the state level, literature indicates an increased risk of psychiatric conditions and poor mental health for adults racialized as Latine living in states with more exclusionary immigration policies67; this may be potentiated among adolescents who fear and/or experience family separation and discrimination.68-70

Adolescents aged 13-14 years racialized as American Indian or Alaska Native had the highest prevalence of depressive symptoms among adolescents. Indeed, close to 1 in 4 American Indian or Alaska Native adolescents aged 13-14 years were in the top quartile of high depressive symptoms in the 2007-2009 cohort. Extensive scholarship has documented the effects of generations of historical trauma on the mental health of American Indian or Alaska Native communities in the United States, which has been described as loss of both human life and culture and language.71-73 These traumas likely unfold in numerous ways, increasing the risk of psychiatric disorders, including depression, for youth racialized as American Indian or Alaska Native through exposure to violence and substance use74 as well as deprivation,74 among other pathways rooted in state violence and neglect. Thus, differences in depressive symptoms among more recent birth cohorts of American Indian or Alaska Native youth may be mediated by continued trauma exposure and increases in parental and familial loss. Efforts to support mental health in communities racialized as American Indian or Alaska Native have been effective when they are collaborative with local communities and participatory; suicide prevention and other mental health initiatives developed by scholars and professionals in American Indian or Alaska Native communities have led to substantial reductions in morbidity and mortality associated with mental health.75 Continued surveillance of and research on youth mental health in communities racialized as American Indian or Alaska Native should center the expertise of Indigenous scholarship and practices to provide support and care for youth.76-78

Birth cohort effects were evident for all adolescents included in the sample, indicative of rapidly increasing depressive symptoms, across age, for the most recent cohorts of adolescents. Given that this study included racialized and minoritized adolescents made vulnerable due to structural and social determinants, it is critical to address access to mental health care.79 Indeed, available national data sources indicate that US racialized and minoritized adolescents with psychiatric disorders remain undertreated in comparison with adolescents racialized as White and that gaps in outpatient mental health care between youth racialized as Black and Latine and their White counterparts have increased during the course of the 21st century.80 Reasons for continued racialized disparities in access to mental health care are numerous, but among the central reasons are a lack of service providers, inadequate identification of adolescents in need of services, and discrimination in health-care settings.81-83 Barriers to effective care have grown, despite efforts to structurally increase access to mental health care through the Affordable Care Act.

Our study also demonstrated that, generally, depressive symptoms peaked during midadolescence and were lower for older adolescents in a given year. While the drivers for this difference are beyond the scope of this study, several hypotheses are worth investigating in future studies, such as the role of academic pressure and school-based discrimination23,24 in the years preceding graduation, as well as increased risk during pubertal transitions that are most likely to occur during midadolescence rather than late adolescence.84,85

Adolescents spend many of their waking hours in school due to compulsory educational mandates, making schools particularly well-suited to provide free screening and treatment for mental health disorders.86 Moreover, most US schools are equipped with monitoring and counseling services for mental health disorders.87 There is growing recognition of the potential public health impact of enhancing school mental health services to promote early screening and service accessibility.88,89 However, a meta-analysis of school-attending youth with elevated mental health symptoms or diagnoses found that only 22% received school-based mental health services,79 suggesting that schools are still experiencing challenges in identifying and retaining students in their mental health services.

While schools may provide a promising locus for adolescent mental health care, the US education system has also historically caused harm to racialized and minoritized groups, which may have contributed to the increasing birth cohort effects for high depressive symptoms observed in our study. Adolescents racialized as American Indian or Alaska Native, who experienced the fastest increasing birth cohort effects for high depressive symptoms, have been severely impacted by racist educational policies for 150 years. The maltreatment and conscious neglect of these children in the care of the education system led to the death at least 500 Indigenous children in the United States,90 with thousands more deaths uncovered in Canadian boarding schools.91,92 Current practices in the US education system continue to perpetuate racist ideology. Numerous studies have shown that charter schools have been associated with increased racial segregation for students racialized as Black, Hispanic/Latine, and White and have widened the standardized test score gap.93-96 Therefore, as public health interventions surveil and treat mental health disorders among racialized and minoritized youth, we must acknowledge the direct role of the US education system in perpetuating structural racism. Moreover, investigators in future studies should consider examining how racial segregation in US charter schools has affected adolescent mental health.

In addition to broad reformations of school-based mental health screening and treatment, equity-based primary prevention approaches are also needed. While programs have been developed using these techniques, including a community-based suicide surveillance system designed for groups racialized as American Indian or Alaska Native,97,98 there are substantial gaps in the development and assessment of similar approaches for other racialized groups and mental health outcomes.

Limitations of this study should be considered. Data were drawn from yearly cross-sectional surveys; birth cohort effects identified were from different adolescents, from the same birth cohort, interviewed in different years. This potentially increased measurement error, and confirmation in longitudinal data sources would be beneficial to test the rigor of these associations. Data on depressive symptoms and other internalizing symptoms were based on self-reports and not clinical interviews; over time and across age, preferences about and acceptability of disclosure of mental health problems may vary, and disclosure may vary across racialized groups. While the depressive symptoms scale we used in this study was not a direct measure of depression or derived from a clinical assessment, it was a useful measure for identifying mood symptoms among adolescents. Moreover, the use of self-reported symptoms is common in national studies, and our measure was similar to those of other studies.99,100 We had limited information regarding where in the United States adolescents were living at the time of the interview; assessing more fine-grained geographic variation by racialized group would be an important next step in this work. However, examination of broad national trends has an important place in epidemiologic surveillance, and it provides a general overview of the state of adolescent mental health in the United States. MTF surveys are done in schools in the United States, and thus non–school-attending adolescents and non-US adolescents were not included in the target population.

We found rapidly increasing levels of depressive symptoms, across age, for the most recent cohorts of racialized adolescents. Increases among more recent birth cohorts were most rapid among adolescents racialized as American Indian or Alaska Native. Public health efforts to reduce these experiences of poor mental health may consider larger barriers (ie, structural, cultural, and linguistic) that limit access to competent mental health providers and efficient school-based mental health services, preventing treatment uptake among racialized and minoritized youth.

Supplementary material

Supplementary material is available at American Journal of Epidemiology online.

Funding

This work was funded by the National Institute of Mental Health (grant 5 T32 MH 13043-50) and the National Institute of Drug Abuse (grant R01-DA048853).

Conflict of interest

The authors declare no conflicts of interest.

Data availability

Data from this study are not available for public use.

Supplementary Material

Web_Material_kwae024
web_material_kwae024.pdf (97.9KB, pdf)

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Associated Data

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Supplementary Materials

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Data Availability Statement

Data from this study are not available for public use.

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